IDENTIFICATION NUMBER: Administrative Code (WAC), …L410 Continued From page 4 consistent with this chapter and services provided; (v) Food service consistent with chapter 246-215

State of Washincfton

PRINTED: 08/05/2019FORM APPROVED

STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:

60429197

(X2) MULTIPLE CONSTRUCTIONA. BUILDING:

B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY.

(X3) DATE SURVEYCOMPLETED

07/26/2019

TATE, ZIP CODE

CASCADE BEHAVIORAL HOSPITAL 1284,4,,MILI1:ARYROAD SOUTH

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SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

INITIAL COMMENTS

STATE LICENSING SURVEY

The Washington State Department of Health(DOH) in accordance with WashingtonAdministrative Code (WAC), Chapter 246-322Private Psychiatric and Alcoholism Hospitals,conducted this health and safety survey.

Onsite dates: 07/23/19 - 07/26/19.

Examination number: 2019-691

The survey was conducted by:

Surveyor #6Surveyor #10

The Washington Fire Protection Bureauconducted the fire life safety inspection,

During the course of the survey, surveyorsassessed issues related to complaint 2019-2838HPSY.

322-025.1A RESP & RIGHTS-COMPLIANCE

WAC 246-322-025 Responsibilities andRights - Licensee and Department. (1)The licensee shall: (a) Comply withthe provisions of chapter 71.12 ROWand this chapter;This Washington Administrative Code is not met

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PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

1. A written PLAN OF CORRECTION isrequired for each deficiency listed on theStatement of Deficiencies.

2, EACH plan of correction statementmust include the following:

The regulation number and/or the tagnumber;

HOW the deficiency will be corrected;

WHO is responsible for making thecorrection;

WHAT will be done to preventreoccurrence and how you will monitor forcontinued compliance; and

WHEN the correction will be completed.

3. Your PLANS OF CORRECTION mustbe returned within 10 calendar days fromthe date you receive the Statement ofDeficiencies. Your Plans of Correctionmust be postmarked by August 16, 2019.

4. Return the ORIGINAL REPORT withthe required signatures.

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DATE

State Form 2567LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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Udo T_N(X6) DATE

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STATE FORM NGVJ11 If continuation sheet 1 of 20

State of WashincjtQji




60429197

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING


07/26/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

CASCADE B^OKAL HOSPITAL ^"^3^ SOUTH

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Continued From page 1

as evidenced by:

Based on observation and record review, thehospital failed to submit its policy for charity carewithin 30 days of adoption to the WashingtonDepartment of Health (Item #1); and failed tomake the policy available on the hospital's publicwebsite (Item #2).

Failure to provide patient rights policies to thepublic risks patients' ability to make informeddecisions regarding access to care.

Reference: RCW 70.170.060 - Current versionsof the hospital's charity care policy, a plainlanguage summary of the hospital's charity carepolicy, and the hospital's charity care applicationfor must be available on the hospital's web site.

WAC 246-453-070 (1) Each hospital shalldevelop, and submit to the department, charitycare policies, procedures, and sliding feeschedules consistent with the requirementsincluded in WAC 246-453-020, 246-453-030,246-452-040, and 246-453-050. Any subsequentmodifications to those policies, procedures, andsliding fee schedules must be submitted to thedepartment no later than thirty days prior to theiradoption by the hospital,

Findings included:

Item #1 Policy update

1. Review of the hospital policies posted on theWashington State Department of Health (DOH)internet website showed that the hospital'sun-dated, un-numbered policy titled "FinancialAssistance and Charity Care," was most recentlyupdated with DOH in January 2014.

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State Form 2567


SState of Washington



(X1) PROVIDER/SUPPL1ER/CLIAIDENTIFICATION NUMBER-.

60429197


A. BUILDING:

B. WING


07/26/2019

NAME OF PROVIDER OR SUPPLIER

CASCADE BEHAVIORAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP CODE

12844 MILITARY ROAD SOUTHTUKWILA,WA 98168

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2. On 07/25/19 at 3:15 PM, the Director of Risk &Quality (Staff #601) provided Surveyor #6 with thehospital's policy number ADM.C.300, titled"Charity Care," approved 02/19. Staff #601 statedit was the current policy for charity care.

Item #2 Charity care access

1. Review of the hospital's internet websiteshowed that neither a policy for charity care, noran application for charity care was available orreferenced.

2. On 05/26/19 at 2:00 PM, during the surveyors'exit conference, the Director of Risk & Quality(Staff #601) confirmed the hospital's internetwebsite had not been updated to include thecurrent policy for charity care.

322-035.1GPOLICIES-EMERGENCYCARE

WAC 246-322-035 Policies andProcedures. (1) The licensee shalldevelop and implement the followingwritten policies and proceduresconsistent with this chapter andservices provided: (g) Emergencymedical care, including: (I) Physicianorders; (ii) Staff actions in theabsence of a physician; (iii) Storingand accessing emergency supplies andequipment;This Washington Administrative Code is not metas evidenced by:

Based on observation, interview, and review ofhospital policies and procedures, the hospitalfailed to ensure staff checked and verified the

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State Form 2567


State of Washington




60429197


A. BUILDING;

B. WING


07/26/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

CASCADE BEHA.OKAL HOSPITAL ^^^D SOUTH

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correct serial-numbered lock when performing adaily Emergency Crash Cart EquipmentChecklist.

Failure to verify the correct serial-numbered lockon the emergency cart could result in a cartwithout the supplies listed within that could riskpotential delays In providing emergency care.

Findings included:

1. Review of the hospital's policy and proceduretitled, "Emergency Cart" policy number PC.C.110,reviewed 01/19, showed that there are seven (7)emergency carts in the hospital and checkednightly by the Charge Nurse. A log fordocumenting daily checks is located on the cartincludes: date, lock serial number, locked Y/N,suction checked Y/N, back board, and signatureof the staff member checking the cart.

2. On 07/24/19 at 2:00 PM, Surveyor #10inspected the emergency cart located on the 3rdfloor North Unit. A review of the emergency cartchecklist for July 2019 showed a lock serialnumber #154254 entered for the last 24 days, onthe list. A closer look at the actual red serial lockshowed a lock number #326884.

3. During an interview on 07/24/19 at 3:50 PM,the North Unit Nurse Manager (Staff #1001)confirmed the incorrect checklist entry.

322-035.1V POLICIES-FOOD SERVICE

WAC 246-322-035 Policies andProcedures. (1) The licensee shalldevelop and implement the followingwritten policies and procedures

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State Form 2567

STATE FORM NGVJ11 Ifcontinuation sheet 4 of 20


State of WashinptonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION


60429197


A. BUILDING:

B. WING


07/26/2019




12844 MILITARY ROAD SOUTHTUKWILA.WA 98168

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L410 Continued From page 4

consistent with this chapter andservices provided; (v) Food serviceconsistent with chapter 246-215WAC and WAC 246-322-230.This Washington Administrative Code is not metas evidenced by:

Based on document review and interview, thehospital failed to develop and implement policiesand procedure to ensure compliance with theWashington State Retail Food Code (Chapter246-215 WAC).

Failure to develop food service policies that directfood preparation and service in compliance withfood safety standards places patients and staff atrisk from food borne illness.

Findings included:

1. On 07/24/19 between 9:00 AM and 10:15 AM,Surveyor #6 toured the kitchen and dining roomwith the Dietary Services Director (Staff #602).During the tour, the surveyor requested a copy ofthe hospital's policy for cooling potentiallyhazardous foods (PHF). Staff #602 provided aninformation sheet copied from the New York StateDepartment of Health's public website.

2. On 07/24/19 at 2:00 PM, during an interviewwith the Director of Risk & Quality (Staff #601),Surveyor #6 requested copies of all food servicepolicies. At 3:15 PM Staff #601 provided copies oftemperature logs, food storage logs, sanitizerlogs, and food safety information handouts. Staff#601 stated that she was not able to locate anyapproved policies related to food sen/ice.

L410

State Form 2567


State of Washington




60429197

(X2» MULTIPLE CONSTRUCT!ON

A. BUILDING:

B. WING


07/26/2019





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322-040,1 ADMIN-ADOPT POLICIES

WAC 246-322-040 Governing Body andAdministration. The governing bodyshall: (1) Adopt written policiesconcerning the purposes, operation andmaintenance of the hospital, and thesafety, care and treatment ofpatients;This Washington Administrative Code is not metas evidenced by:

Based on interview, medical record review, andreview of the hospital's policies and procedures,the hospital failed to assure that policies andprocedures were reviewed and revised to reflectcurrent clinical practice.

Failure to review and revise policies to reflectcurrent practice prevents the hospital staff fromcarrying out all of the functions of the organizationand risks unsafe, inconsistent patient care.

Findings included:

1. Record review of the hospital's policy andprocedure titled, "Policies and Procedures," policy#ADIV1.P.500 reviewed 05/19, showed that thehospital will have policies and procedures in placethat will reflect evidence-based practice andguide staff to carry out all of the functions of thehospital to promote safe, consistent, high-qualitycare.

a. Record review of the hospital's policy andprocedure titled, "Diabetes: Patient Care," policy#PC.D.200 reviewed 02/19, showed that staff willtreat a blood sugar level below 70 by following thehypoglycemia protocol and staff will not withholdscheduled insulin doses. For treatment of high or

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State Form 2567STATE FORM NGVJ11 If continuation sheet 6 of 20

State of Washinqton




60429197


B. WING


07/26/2019




12844 MILITARY ROAD SOUTHTUKWILA.WA 98168

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low blood sugar levels, staff will foilow physicianorders and/or Cascade Behavioral Hospitalnursing procedure.

b. Record review of the hospital's pharmacypolicy and procedure titled, "IntravenousTherapy," policy #MM.05.01.07 reviewed 05/18,showed that the hospital offers no intravenoustherapy services (no IV solutions or supplies) anda home health agency will administer allintravenous medication on site.

2. Review of Patient #1 001 's medical record on07/24/19 at 1:25 PM, showed a pre-printed ordersheet to guide staff on the treatment of thepatient's blood glucose levels. Review of theorder form showed it was labeled with thepatient's ID stamp and a hand written noteshowing orders were faxed to pharmacy. The topof the form showed orders for monitoring thepatient's blood glucose (before meals & atbedtime), showed Regimen #1 and #2 guidelinesfor supplemental insulin according to the currentpatient's blood glucose level, and the bottom ofthe form showed the hypoglycemia protocol.

The hypoglycemia protocol provides steps thatstaff will follow to treat a diabetic patient with ablood glucose level

State ofWashinfiton




60429197


B. WING


07/26/2019

NAME OF PROVfDER OR SUPPLIER


STREET ADDRESS. CITY, STATE, ZIP CODE

12844 MILITARY ROAD SOUTHTUKW1LA,WA 98168

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3. During an interview on 07/24/19 at 2:00 PM,the Chief Nursing Officer [CNO] (Staff #1002)confirmed that the hospital does not provide staffsupplies or medications to administer medicationintravenously. The CNO was asked how staffcould follow the hypoglycemia protocol for Patient#1001 if the hospital does not provide intravenousservices. The CNO stated that if the patient'sblood glucose level reaches a critical point andbecomes unconscious, then staff are to call 911.

4. During an interview on 07/25/19 at 1:00 PM,the hospital's Pharmacist (Staff #1003) reviewedPatient #1001's blood glucose order form andrevealed that the form's approval date (showed inthe footer) was 05/18. The Pharmacist alsostated that the hospital does not stock D50Wintravenous solutions and it is not available. Hestated that the pre-printed blood glucose orderform will need to be reviewed and revised by theP & T committee.

322-100.1E INFECT CONTROL-PROVISIONS

WAC 246-322-100 Infection Control.The licensee shall: (1) Establish andimplement an effective hospital-wideinfection control program, whichincludes at a minimum: (f) Provisionsfor: (i) Providing consultationregarding patient care practices,equipment and supplies which mayinfluence the risk of infection;(ii) Providing consultation regardingappropriate procedures and productsfor cleaning, disinfecting andsterilizing; (iii) Providing infection

L 420

L715

State Form 2567


State of Washinaton


STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTfON


60429197


A, BUILDING:

B. WING


07/26/2019





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control information for orientationancf in-service education for staffproviding direct patient care; (iv)Making recommendations, consistentwith federal, state, and locallaws and rules, for methods of safeand sanitary disposal of: (A)Sewage; (B) Solid and liquid wastes;and (C) Infectious wastes includingsafe management of sharps;This Washington Administrative Code is not metas evidenced by:

Based on observation, interview, and documentreview, the hospital failed to implement aneffective procedure to monitor the physicalenvironment for situations that support the growthof microorganisms that could spread infectiousdisease.

Failure to prevent the growth and spread ofwaterborne pathogens places patients, staff, andvisitors at risk for infections.

Reference: CDC Legionelia Toolkit, Developing aWater Management Program to ReduceLegionella Growth & Spread in Buildings; APractical Guide to Implementing IndustryStandards, updated 05/15/17. Elements of aneffective water management program includeidentification of areas where water could pool andstagnate, apply and monitor control measures,establish corrective actions to intervene whencontrols are not met, evaluate the program'seffectiveness, and document the activities.

Findings included:

1. Document review of the hospital's policy titled,"Water Management Plan," Policy #F.WMP. 100

L715

State Form 2567


PRINTED; 08/05/2019FORM APPROVED

State of WashinatonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION


60429197


A. BUILDING;

B. WING


07/26/2019





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approved 11/18, showed that ice/water dispenserdrain lines are not identified as areas where watercould pool and stagnate; control measures/limits,including elimination of stagnant water andmonitoring disinfectant levels are not identified;corrective actions do not address equipmentdrain lines; and the verification process(evaluation) refers to semiannual testing withoutidentifying testing protocols.

Document review of Follett Symphony series Iceand Water Dispensers Installation, Operation andService Manual showed that drains must maintainat least 1/4-inch per foot of slope on horizontalruns.

2. During the survey, Surveyor #6 made thefollowing observations of 6 ice/water dispensers:

a. On 07/23/19 at 2:00 PM, Surveyor #6 touredUnit 2-W with the Chief Nursing Officer (CNO)(Staff #603). Surveyor #6 observed a Follettbrand Symphony series ice/water dispenser in thedining room. The lce/water dispenser's drain lineran horizontally with a dip that allowed water topool. The drain line did not maintain the requiredslope.

b. On 07/24/19 at 10:10 AM, Surveyor #6 touredthe hospital's kitchen and cafeteria with theDietary Director (Staff #609). Surveyor #6observed a Hoshizaki brand ice/water dispenserwith a clear PVC (polyvinyi chloride) drain hosethat rested horizontally across the flat surface of acabinet for a length of approximately 2-feet. Thedrain hose showed significant black slimeaccumulation indicating bacterial growth.

c. On 07/24/19 at 10:55 AM, Surveyor #6 touredUnit 2-N with the Nurse Manager (Staff #609).

L715

State Form 2567

STATE FORM NGVJ11 if continuation sheet 10 of 20

State of'Washinqton




60429197


A. BUILDING:

B. WING


07/26/2019





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Surveyor #6 observed a Follett brand Symphonyseries ice/water dispenser in the Day Room. Theice/water dispenser's drain line ran horizontallywith a dip that allowed water to pool. The drainline did not maintain the required slope.

d. On 07/25/19 at 10:50 AM, Surveyor #6 touredUnit 3-N with the Nurse Manager (Staff #610) andthe Director of Facilities (Staff #606). Surveyor #6observed a Follett brand Symphony seriesice/water dispenser in the Clean Utility room. Theice/water dispenser's drain line ran through anopening in the countertop and was not visible.Staff #606 stated that special tools were requiredto access the space below the countertop andthat the drain line installation was the same asother countertop ice/water dispensers. Staff #606stated he did not know whether the drain linemaintained the required slope.

e. On 07/25/19 at 11:30 AM, Surveyor #6 touredUnit 3-W with the Nurse Manager (Staff #611)and the Director of Facilities (Staff #606).Surveyor #6 observed a Follett brand Symphonyseries ice/water dispenser in the pantry for thedining room. The ice/water dispenser's drain lineran through an opening in the countertop and wasnot visible. Staff #606 stated that special toolswere required to access the space below thecountertop and that the drain line installation wasthe same as other countertop ice/waterdispensers. Staff #606 stated he did not knowwhether the drain line maintained the requiredslope.

f. On 07/25/19 at 11:45 AM, Surveyor #6 touredUnit 4-W with the Nurse Manager (Staff #611)and the Director of Facilities (Staff #606).Surveyor #6 observed a Follett brand Symphonyseries ice/water dispenser in the Clean Utility

L715


State ofWashinflton




60429197


A. BUILDING:

B. WING


07/26/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE

CASCAOH B.HAVIOR^ HOSPITAL :S^S:D SOUTH

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room. The ice/water dispenser's drip tray was fullof water (not draining). The drain line ran throughan opening in the countertop and was not visible.Staff #606 stated that special tools were requiredto access the space below the countertop andthat the drain line installation was the same asother ice/water dispensers. Staff #606 stated hedid not know whether the drain line maintainedthe required slope.

322-120.7 MAINTENANCE P&P

WAC 246-322-120 Physical EnvironmentThe licensee shall: (7) Implementcurrent, written policies, procedures,and schedules for maintenance andhousekeeping functions;This Washington Administrative Code is not metas evidenced by:

Based on observation, document review, andinterview, the hospital failed to ensure that staffmembers properly performed housekeepingfunctions, including failure to maintain a cleanenvironment (1), failure to maintain environmentalsurfaces in smooth, non-absorbent, and easilycleanable condition (2), and failure to adequatelyand effectively disinfect environmental surfaces inpatient rooms (3).

Failure to properly perform housekeepingfunctions places patients, staff, and visitors at riskof increased exposure to allergens and harmfulmlcroorganisms.

Findings included:

Item #1 - Clean environment

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State ofWashinqton




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L 815 Continued From page 12

Reference: Guidelines for EnvironmentalInfection Control in Health-Care Facilities.Recommendations from CDC and the HealthcareInfection Control Practices Advisory Committee(HICPAC), 2003; updated July 2019. Pg. 147. ERecommendations - Environmental Services;subsection E. Keep housekeeping surfaces (e.g.,floors, walls, and tabletops) visibly clean on aregular basis and clean up spills promptly.

1. Document review of the hospital's policy titled,"Belongings (Patient)," policy #PC.B.100reviewed 02/19, showed that the hospital shouldprovide for safe and appropriate management ofpatients' personal belongings.

Document review of the hospital's documenttitled, "Quick Reference: EnvironmentalCleaning," revised 10/17, showed that equipmentwith visibly soiled surfaces should be scrubbedwith a cleaner/detergent or disinfectant.

2. On 07/23/19 from 10:50 AM to 3:10 PM,Surveyor #6 toured patient care areas with theChief Nursing Officer (CNO) (Staff #603). Theobservations showed unclean areas, excessiveamounts of dirt, dust, and debris, and items/areaswhose readiness for use could not bedetermined;

a. Room #103 (used for video court) - patientcare equipment that could not be identified asclean or disinfected, or whether it had been used:a wheelchair, a disposable, cone-style face maskhanging from a push handle of the wheelchair, 2sets of cloth restraints lying on the seat of thewheelchair, 2 Ambu® disposable face masksloose in a drawer.

b. Assessment Room #4 (used for medicalA/ital

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State of WashinfltonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION


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signs assessment) - no sanitizer/disinfectantwasavailable for sanitizing patient care items afteruse. There was no indicator that informed staffwhether the room was ready for use.

c. Assessment Room #2 " contained soiledclothing and discarded paper products. Therewas no indicator that informed staff whether theroom was ready for use.

d. Patient Belongings Storage (Room 4 in the "oldsurgical suite") - over-flowing garbage bin, trashon the floor throughout the room, disorganizedstorage of patient belongings on the floor andshelves intermingled with debris.

e. Soiled Utility on Unit 2-W - stained surfaceunder the sink, dirt & debris along floor coving.

f. An OfficeA/isitation Room on Unit 2-W - dirt &debris on the floor.

3. On 07/23/19 at 11:15 AM. Surveyor #6interviewed Staff #603 and a Milieu Specialist(Staff #605) about the patient care items listed inRoom #103. Staff #605 stated that the wheelchairshould have been disinfected after patient use,but that she did not know whether that had beendone. Staff #605 stated she did not know of apolicy or procedure to launder cloth restraints,and that they might have been used up to 5 timesin the past year without being cleaned or sanitizedafter patient use. Staff #603 stated that theAmbu® bags were probably left over from aprevious hospital facility.

4. On 07/24/19 from 10:40 AM to 1:45 PM,Surveyor #6 toured patient care areas with theDirector of Risk & Quality (Staff #601). Theobservation showed unclean areas and

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accumulation of dirt, dust, and debris:

a. Clean Utility on Unit 2-N " an electric razorblade guard was covered with whisker debris, theemergency cart had a layer of dust on the topsurface, 2 bladder scanners and a patient vitalsigns monitor had dried debris on the housingsurfaces; 3 rolling stands for patient careequipment had dust and debris on their surfaces.

b. Seclusion room on Unit 2"N - accumulation ofdust in the corners & along the bed pedestal.

c. Shower/toilet Room #386 on Unit 3-S-significant dust accumulation on exhaust fancover.

Item #2 - Cleanable surfaces

1. On 07/23/19 at 12:00 PM, during a tour ofpatient intake areas with the CNO (Staff #603),Surveyor #6 observed a couch in AssessmentRoom 2 with a tear in the vinyl upholstery suchthat the cloth padding was exposed. Cloth isabsorbent and not a cleanabte surface.

2. At the time of the observation, the surveyorasked Staff #603 about the torn vinyl. Staff #603stated that a repair request would be madeimmediately.

3. On 07/24/19 at 10:55 AM, during a tour ofpatient care areas with the Director of Risk &Quality (Staff #601), Surveyor #6 observeduncleanable surfaces in the Unit 2-N Dayroom:

a. Five chairs with worn vinyl upholstery such thatthe structural mesh fabric was exposed. Themesh fabric is absorbent and not a cleanablesurface.

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State Form 2567



State of WashinqtonSTATEMENT OF DERCIENCIESAND PLAN OF CORRECTION


60429197


A. BUILDING:

B. WING


07/26/2019




12844 MILITARY ROAD SOUTHTUKW1LA,WA 98168

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b. Wall surfaces along the window and on asupport column had deep gouges such thatsheetrock was exposed. Sheetrock is absorbentand not a cleanable surface.

4. At the time of the observations, the surveyorasked Staff #601 about the worn vinyl andgouges in the wall. Staff #601 stated that thosesurfaces should be repaired.

5. On 07/25/19 at 11:45 AM, during a tour ofpatient care areas with the Director of Facilities(Staff #606), Surveyor #6 observed uncleanablesurfaces in the Unit 4-W Clean Utility:

a. Counter edges and cabinet doors had areas ofbroken and missing laminate such that particleboard was exposed. Particle board is absorbentand not a cleanable surface.

b. Drawers and cabinet surfaces had areas ofswollen particle board.

6. At the time of the observations, the surveyorasked the Unit 4-W Nurse Manager (Staff #611)about the exposed and swollen particle board.Staff #611 stated that the surfaces were notcleanable,

Item #3 - Disinfection of environmental surfaces

1. Reference Sheet Virex II 256 - EPAReg. No.70627-24 states that all surfaces must remainwet for 10 minutes.

Document review of the hospital's policy titled,"Daily Cleaning of Toilet - Tub," Policy #ES.D.300dated 06/19, showed that facility staff are to useVirex 256 disinfectant solution to clean toilet seat,

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State Form 2567

STATE FORM NGVJ11 If continuation sheet 16of20


_ State of'lA/ashinqton.STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION


60429197


A. BUILDING:

B. WING


07/26/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE

CASC.OB BEHAVIOP.L HOSPITAL :S^3Rr SOUTH

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top, and underneath and around hinge.

2. On 07/25/19 at 10:30 PM, Surveyor #6observed a housekeeper (Staff #607) perform aterminal cleaning of Patient Room #392 on Unit3-N, During the process, the surveyor observedineffective disinfectant use:

a. Staff #607 used a wiping cloth that had beensoaked in Virex II 256 (a quaternary disinfectantsolution) to wipe surfaces around the room.When disinfecting the door handles and mirror,Staff #607 wiped the surfaces with thedisinfectant cloth and then immediately wiped thesurfaces with a dry cloth.

b. Staff #607 used a disinfectant soaked cloth towipe the toilet bowl but used a dry cloth to wipethe toilet seat, top, and underneath.

3. At the time of the observations, Surveyor #6asked Staff #607 about the disinfectant solution.Staff #607 stated that the solution was Virex andthat surfaces must remain wet 10 minute for thedisinfectant to be effective.

322-230.1 FOOD SERVICE REGS

WAC 246-322-230 Food and DietaryServices. The licensee shall: (1)Comply with chapters 246-215 and246-217 WAC, food service;This Washington Administrative Code is not metas evidenced by:

Based on observation, interview, and documentreview, the hospital failed to implement policiesand procedures consistent with the WashingtonState Retail Food Code (Chapter 246-215 WAC).

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State Form 2567

STATE FORM NGVJ11 !f continuation sheet 17 of 20

6tate of Washington



(X1) PROVfDER/SUPPLIER/CLIAIDENTIFICATION NUMBER;

60429197


A. BUILDING:

B. WING


07/26/2019





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Failure to follow food safety standards placespatients at risk from food borne illness.

Findings included:

Item #1 Potentially Hazardous Foods (PHF)temperature control

1. On 07/24/19 between 9:10 AM and 10:30 AM,Surveyor #6 toured the hospital's kitchen andcafeteria with the Dietary Director (Staff #609).Surveyor #6 requested a copy of the hospital'spolicy for cooling potentially hazardous foods(PHF). Staff #609 provided an information sheettitled, "Cooling and Reheating of PotentiallyHazardous Foods." Review of the informationsheet showed that it is a page from the New YorkState Department of Health's public website. Thedocument directs that PHFs must be cooled to 45degrees Fahrenheit. Washington State RetailFood Code requires PHFs to be cooled to 41degrees Fahrenheit.

Reference: Washington State Retail Food Code(WAG) 246-215-03515; WAC 246-215-03520

2. During the survey, Surveyor #6 made thefollowing observations of phf cold holdingtemperatures that exceeded the requiredmaximum of41 degrees Fahrenheit:

a. Unit 2-W pantry: Yi pint milk - 45.4 degreesFahrenheit; 6-oz container of yogurt - 49.1degrees Fahrenheit;

b. Unit 3-W pantry: Vi pint milk" 45 degreesFahrenheit; cheese stick - 51 degreesFahrenheit.

L1485

State Form 2567

STATE FORM NO VJ 11 If continuation sheet 18 of 20


State of WashinqtonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X1) PROV1DER/SUPPLIER/CLIAIDENTIFICATION NUMBER:

60429197


A. BUILDING:

B, WING


07/26/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE

CASCAOB B.HAVIO^ HOSPITAL :S^3Rr SOUTH

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Reference: Washington State Retail Food Code246-215-03525

Item #2 Handwashing sink

3. On 07/24/19 at 10:10 AM, Surveyor #6inspected the cafeteria. The surveyor observedthere was no handwashing sink near the cafeteriatray line, where staff plate and serve ready-to-eatfood.

4. At the time of the observation, Surveyor #6interviewed a food service worker (Staff #612)about handwashing during food service at the trayline. Staff #612 stated that staff could use ahandwashing sink in the kitchen.

The nearest handwashing sink to the cafeteria isthrough a latching door, across a hallway, andthrough another doorway. The nearesthandwashing sink does not allow convenient useby food employees, as required.

Reference: Washington State Retail Food Code246-215-05255

322-240.4A LAUNDRY-WATER TEMPERATURE

WAG 246-322-240 Laundry. The licenseeshall provide: (4) When laundry iswashed on the premises: (a) Anadequate water supply and a minimumwater temperature of 140 F in washingmachines;This Washington Administrative Code is not metas evidenced by:

Based on obsen/ation and interview, the hospitalfailed to ensure the water supply used for on-site

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(X5)COMPLETE

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State of WashinfltonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION


60429197


A. BUILDING:

B. WING


07/26/2019





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patient laundry services reaches a minimumtemperature of 140 degrees Fahrenheit.

Failure to use sufficiently hot wash water placespatients at risk of illness due to insufficientreduction of microbial contamination in patientlaundry.

Findings included:

1. On 07/24/19 at 9:10 AM, Surveyor #6 used aninstant read thermometer to assess thetemperature of hot water at a handwashing sinkin the hospital kitchen. The temperature wasassessed at 116.8 degrees Fahrenheit after 90seconds.

At 11:05 AM, Surveyor #6 used an instant readthermometer to assess the temperature of hotwater at the service sink in the Soiled Utility roomon Unit 2-N. The temperature was assessed at104.1 degrees Fahrenheit after 3 minutes.

2. On 07/25/19 at 10:00 AM, Surveyor #6interviewed the Facilities Director (Staff #606)and the CNO (Staff #603) about hot watertemperature available to the on-site washingmachines for patient laundry. Staff #606 statedthat each patient unit had a domestic washingmachine and that the hot water source for eachmachine was the same system that serves therest of the hospital. Staff #606 stated that none ofthe washing machines had heat boosters to raisethe water temperature to the required minimumtemperature of 140 degrees Fahrenheit.

L1565


CASCADE BEHAVIORAL HEALTHPlan of Correction for

State Licensing Survey

July 23-26, 2019

TagNumber

L 070

L 335

L 410

How the Deficiency Wilt Be Corrected

Charity Care policy: The Chief FinancialOfficer revised the current Charity Care

policy ADM.C.300 and submitted it to theDepartment of Health. It will be

upioaded to Cascades website by8/30/19.

Crash Cart: A new log will beimplemented by 8/23/19 on all crashcarts. All crash carts will be opened,

expiration dates noted on all supplies inthe carts and carts will be re-locked on8/23/19. All nursing staff will be

educated on the new logs and how to

complete them properly on 8/29/19.Follow up education will be provided tothose who do not attend the 8/29/19nursing staff meeting.

Foodborne Illness policy: The hospital's

policies on foodborne illness were not

located at the time of survey. Policies

were subsequently located and placed inthe proper location on our public drive.

Cooling foods policy: A policy for coolingpotentially hazardous foods will bedeveloped. Ail dietary staff will beeducated on this policy. This policy willbe submitted for approval by QualityCouncil and the Medicai Executive

Responsible Individual(s)

Chief Financial Officer

Chief Nursing Officer

Dietary Manager

Dietary Manager

Estimated Date ofCorrection

8/14/19 submitted toDepartment ofHealth

8/30/19 upload toCascade's website.

New logs and audits

will begin on 8/23/19and continue for a

minimum of 3months to ensure

sustained

compliance.

8/16/19

9/13/19

Monitoring procedure; Target for Compliance

The Chief Financial Officer will be responsible

for ensuring the Department of Health has themost current copy of the hospital's CharityCare policy annually. Cascade's website will

reflect the same policy as well as an

applicationfor charity care. Target forcompliance is 8/30/19

Nursing Supervisors will audit the crash carts

and the logs on a daily basis to ensuresustained compliance. Any deficiencies will be

corrected immediately and staff will be re-

educated if necessary. Target for compliance is

8/23/19

Dietary Manager re-educated regarding policy

location and content.

Kitchen staff will be educated on the CoolingFoods policy. New staff will receive education

upon hire. Dietary Manager will continue tomonitor the temperatures and timeframes

while cooling foods.

L 420

L 715

Committee during their August monthlymeetings.

Intravenous Fluids: Both the pharmacy

and hospital policies will be revised toremove instructions on treatment with

intravenous fluids. The policy changeswill go through The Pharmacy andTherapeutics Committee/ Quality Counciland Medical Executive Committee attheir regularly scheduled Augustmeetings. All clinical staff will beeducated regarding the changes in the

policies after final approval by the abovecommittees.

Water Management plan: The Water

Management policy will be revised toinclude the identification of ice/waterdrain lines as a place where water could

stagnate; control measures/limits

including the elimination of stagnantwater and the monitoring of disinfectantieveis. Verification process during

semiannual testing identifies testing

protocols and parameters.

Ice Machines: All ice machines drain

lines were inspected and adjusted tomeet the standard slope requirement on

8/5/19. 2W drain line was reinstalled/kitchen line was replaced and reinstalled,

2N reinstalled/ 3N checked and was atthe appropriate slope/ 3W checked andwas at the appropriate slope, 4W

checked and was at the appropriateslope. Additionally/ all the ice machines

have a built in drain separation inside theunits themselves to prevent backfill of

any kind.

Chief Medical Officer, LeadPharmacist & Chief

Nursing Officer

Director of Facilities


8/30/19

9/27/19

8/5/19

New polices will be approved and clinical staffwill be educated by August 30th, 2019.The Chief Nursing Officer, Chief MedicalOfficer and Lead Pharmacist reviewed all otherpolicies to ensure no others mentioned

intravenous therapy.

The Water Management monitoring

procedure will be developed and implementedby 9/27/19. Director of Facilities will reportwater management activities monthly to CEO

moving forward.

Inspected/corrected 8/5/19. Monthlyinspections of ice machine drain lines for any

buildup, biockage and for correct slope by theDirector of Facilities will begin 9/2/19.

L 815Clean Environment: Belongings room

Housekeeping staff completed a deepclean of the belongings room on 8/5/19.Housekeeping staff will dean this areadaily moving forward.

Clean Environment: CourtWheel chair for court was cleaned.

Cleaning/disinfecting wipes were stockedin the court area. Ambu bags were

disposed of. Cloth Restraints were

laundered. Nursing and court staff were

educated on the mandatory cleaning ofthese items after each patient use:

wheelchair, restraints and any other

items that are used on a patient. A

clipboard with a log was implemented todemonstrate that these items are

cleaned after every patient use.

Clean environment: Assessment rooms

Staff have been provided with wipes for

cleaning equipment and other surfaces

between patients. A clipboard is postedto demonstrate when each room was

last cleaned. The Dynamap (vital signmachine) was relocated to the

admissions area and staff were trained

regarding the new location for its storageand cleaning.

All staff who discharge or admit patientsin these rooms have been instructed to

clean the room after the patient has

discharged and document the cleaningon the clipboard.

The Director of Facilities is researchingoptions for indicators to be placedoutside the doors of these rooms to

indicate if the room is in use/dirty or



Chief Nursing Officer,Director of intake. Director

of Facilities & Infection

Control Nurse

8/5/19

8/5/19

8/30/19

Deep cleaning occurred on 8/5/19. Dailycleaning began 8/6/19. Director of Facilitieswill monitor this area weekly for cleanliness.

Director of Facilities will include the

monitoring of the cleaning and completion ofthe log on his monthly rounds beginning

9/2/19.

Intake staff and Nurse Supervisors wii! assess

all of the rooms daily at random intervals for

maintained compliance starting 8/30/19. Anyrooms found out of compliance will beimmediately cleaned and staff responsible wiiireceive 1:1 on the spot re-education.

Infection Controi nurse will add these rooms

to their monthly rounding and report anyfindings to CNO, Director of Intake andDirector of Facilities starting 8/30/19.

available/dean to install by 9/30/19.Housekeeping staff thoroughly clean allassessment rooms in the Intake areas

once daily.

Clean environment: 2N Clean utilityroom. Electric trimmer was removed and

discarded. Disposable trimmers were

purchased last year, staff reminded touse only those trimmers with thedisposable heads and to clean the basebetween each patient use. No other

reusable trimmers remain at Cascade.

Housekeeping staff were re-educated on

cleaning all surfaces to include the crashcart tops.

Nursing staff educated to clean allpatient care equipment after each

patients use and if the item needs a

more thorough clean on the bases or

stands, they are to inform the Director of

Facilities.

Clean Environment; Cleanable Surfaces

A complete hospital inspection wascompleted on furniture in patient care

areas. Chairs were removed from the

units/ soiled or damaged coverings were

replaced with replaced with new vinyl on8/2/19. The couch in assessment room 2was sent out for repair and replaced with

additional chairs until its return.

Wall surface damage has been repaired

and repainted in 2N.

4 west utility room broken and missinglaminate on counter edges, cabinet

doors and drawers are scheduled to be

Director of NursingDirector of Facilitiesinfection Control Nurse

Director of FacilitiesInfection Control Nurse

8/6/19

9/25/19

Infection Control has added patient care

equipment to their monthly rounds and willnotify Director of Nursing and the Director of

Facilities if any items are in need of cleaning.Monthly Founding begins in August 2019.

infection Control has added the inspection of

all furniture to their monthly rounds and wiflreport any findings or soiled or damagedfurniture to the Director of Facilities monthlyfor immediate removal or repair. Monthly

rounding begins in August 2019.Infection control will also monitor all cleanablesurfaces to include cabinets/ countertops/

walls and floors on their monthly rounds forany damage and inform the Director of

Facilities immediately/ if discovered/ to initiatea work order for repair.

L 1485

repaired/replaced by an external vendoron 9/25/19

Clean Environment: 2W soiled utilityroom, 21M seclusion room &

office/visitation room have been deepcleaned. Housekeeping was re-educated

about getting floor corners cleaned in ailareas of the hospital. The area below thesink on 2W has been cleaned andsecured closed with screws.

Clean Environment Shower/toiletexhaust fans: All exhaust fans have been

cleaned. They will be externally cleanedby housekeeping daily moving forward.Preventative maintenance is performed

every 3 months where the exhaust fans

are opened, assessed for proper

functionality, oiled & deep cleaned.

Clean Environment: Ineffectivedisinfectant use. All Housekeeping staffattended mandatory training on CleaningProcedures and proper disinfectant use

on 8/9/19. They will also receiveadditional training from the cleaningvendor on 8/22/19 on disinfectant dwelltimes and cleaning procedures.

Potentially Hazardous Foods: A policyfor cooling potentially hazardous foodswil! be developed and implemented by9/13/19. All dietary staff will be

educated on this policy. This policy willbe formally approved in Quality Counciland the Medical Executive Committeeduring their August monthly meetings.


Infection Control Nurse



Dietary ManagerDirector of FacilitiesInfection Control Nurse

8/16/19

8/16/19

8/22/19

9/13/19

Director of Facilities and Infection Control willround monthly to assess the cleanliness of

these areas. Any accumulation of dust, dirt or

debris will be reported to Housekeeping toaddress immediately. Specialized training withcleaning vendor is scheduled on 8/22/19 for

all housekeeping staff. Director of Facilitieswill follow up with individual staff regarding

job performance.

The Director of Facilities and Infection Control

have added the inspection ofshower/toiletexhaust fans to their monthly rounds forinspection. Any findings will be reported forimmediate attention.

The Director of Facilities will observehousekeeping staff during his monthly roundsand provide immediate 1:1 correction ifneeded. The infection Contro! will observe a

minimum of one housekeeper monthly duringtheir surveillance rounds and report any

deviation from proper process to the Directorof Facilities.

Dietary Manager will ensure all new staff are

trained on this policy upon hire. Random spot

checks of appropriate temperatures will occur

monthly by the Dietary Manager and theinfection Control Nurse. Ali findings will bereported to the Director of Nursing as well as

the Director of Risk & Quality with anexpected compliance of 100%. This will be

L1565

Patient refrigerators: All patientrefrigerators were inspected by theDirector of Facilities by 8/16/19 andwere found to be in good working order.

It was determined that dietary staff wereallowing nursing to stock therefrigerators and staff have been

stocking the patient refrigeratorsexcessively. Nursing staff have been

instructed to call the kitchen if they runout of a particular item prior to the next

delivery.

Handwashing sink in Cafeteria: Anew

handwashing sink will be installed in thecafeteria. This will require coordination

with the Department of HealthConstruction Review Service and

installation of new plumbing.

Laundry water temperature: New hot

water boosters will be ordered to bring

the temperature of the water in allpatient washing machines to 140 F. This

will require major work pertaining to theinstillation of dedicated electrical and

plumbing to all patient units ascoordination with the Department ofHealth Construction Review Service..

Dietary Manager




8/16/19

1/26/20

5/26/20

followed for 3 months to ensure sustained

compliance. Target date 9/13/19 to developand implement policy as well as train staff.

Moving forward only dietary staff will stock asmaller par level of supplies in ail of thepatient refrigerators on the units. This willprevent overstocking and maintain

temperature control inside the refrigerators.

Refrigerator temperatures are monitored

monthly by infection Control/ daily by Directorof Dietary and monthly by the Director ofFacilities. Any deviation outside the acceptable

temperature range will immediately bereported to the Director of Facilities.

Working with Department of HealthConstruction Review. Mitigation plan until

construction is complete: a portable

handwashing station will be purchased andplaced in the cafeteria.

Working with Department of HealthConstruction Review Service. Mitigation plan

until construction is complete: Patient iaundry

will contain a chemical additive to decreasethe risk of illness due to insufficient reductionof microbial contamination until hot waterboosters are installed.

.- ^yA:-rt^/J^/

c^.f^n^/1/ ^7 A

CASCADE BEHAVIORAL HEALTHPlan of Correction for

State Licensing Survey

July 23-26,2019

.€ i'^e-L

^ i!,-

AUG 2 7 2019 ^-t'^^^-i!^^/"'

^ySETOS"*IVIonitoring procedure^ Tai^el

^ ?u< ^- /Y

TagNumber

How the Deficiency Will Be Corrected Responsible Individuals) Estimated Date ofCorrection

ipliance

L 410 Food Service Policies: The hospital'sfood semce policies were not located at

the time of survey. Policies will be

developed to address food preparation/

cooiing, cold & hot food holding, and

'storage to meet Washington State Retail

Food Code standards. These policies will

be submitted for approval by QualityCouncil and the Medical Executive

Committee during their Septembermonthly meetings.

Dietary Manager 9/30/19 Dietary Manager to re-educate staff regardingnew policies and how to reference them.

Kitchen staff will be educated on all policies.

New staff will receive education upon hire.

Dietary Managerwill continue to monitor

compliance. 100% compliance goal to beachieved by 10/1/2019. Monthly audit resultsreported to Quality Council

L 815 Clean EnvironmentRoom #103 Video Court.

Wheel chairfor court was cleaned.CieanEng/dismfecting wipes were stocked

in the court area. Ambu bags were

disposed of. Cloth Restraints were

laundered. Nursing and court staff were

educated on the mandatory cleaning of

these items after each patient use:

wheetchair/ restraints and any other

items that are used on a patient. A

clipboard with a log was implemented todemonstrste that these items are

cleaned after ever/ patient use.

Assessment rooms #2 and #4.

Staff have been provided with wipes for

cleaning equipment and other surfaces

between patients. A clipboard is posted

to demonstrate when each room was

last cieaned. The Dynamap (vital sign

Director of Facilities 9/3/19

Chief Nursing Officer,Director of Intake/ Directorof Facilities & [infectionControl Nurse

8/30/19

Director of Facilities will incEude themonitoring of the deaning and completion of

the log on his monthly rounds beginning

9/3/19,

Intake staff and Nursing supervisors will assess

ail of the rooms daily at random intervals for

maintained compliance starting 8/30/19. Anyrooms found out of compliance will be

immediately cleaned and staff responsible will

receive 1:1 on the spot re-educatio.n.

between each patient use. No otherreusable trimmers remain at Cascade.

Housekeeping staff were re-educated oncleaning all surfaces to include the crash

cart tops (see cieanabie surfaces beiow).

Mursing staff educated to clean al!

patient care equipment after each

patients use and if the item needs a

more thorough dean on the bases or

stands/ they are to Inform the Director of

Faciiities.

Cleanable Surfaces

Afuil hospital inspection was completed

to ensure that furniture is in good repair

with intact/ cleanable surfaces. Damaged

or soiled fu miture was removed from

the units/ and soiled or damaged

coverings were replaced with replacedwith new vinyi on 8/2/19. The couch inassessment room 2 was sent out for

repair and replaced with additional

chairs until its return. Wall surface

damage has been repaired and repainted

m 2N.4 west utiitty room broken and

missing laminate on counter edges/cabinet doors and drawers are scheduled

to be repaired/replaced by an externalvendor on 9/25/19

Shower/toilet exhaust fans. A!l exhaust

fans have been cleaned. They will be

externally cleaned by housekeeping daily

moving forward. Preventative

maintenance is performed every 3

months where the exhaust fans are

opened, assessed for proper

functionality/ oiled & deep cleaned.



/•



8/16/1&

8/22/19

Infection Control has added the inspection ofall furniture to their monthiy rounds and willreport any findings or soiled or damagedfurniture to the Director of Facilities monthly

for immediate removal or repair. Monthiy

Founding begins in August 2019.

infection control will also monitor alE cleanable.

surfaces to include cabinets/ countertops/

walls and floors on their monthly rounds for

any damage and inform the Director of

Facilities immediately, if discovered, to initiate

a work order for repair.

The Director of Facilities and Infection Control

have added the inspection ofshower/toilet

exhaust fans to their monthly rounds for

inspection. Any findings will be reported forimmediate attention.

L 1485

Disinfection of Environmental Surfaces

Ineffective disinfectant use. AilHousekeeping staff attended mandaton/

training on Cleaning Procedures andproper disinfectant use on 8/9/19. They

will also receive additional training fromthedeaningvendoron 8/22/19 on

disinfectant dweil times and cleaning

procedures.

Policies wil! be developed to meet

Washington State Retail Food Codestandards. These policies will be

submitted for approval by Quality

Council and the Medicai Executive

Committee during their September

monthfy meetings.

Potentiaify Hazardous Foods: A policy

for cooling potentially hazardous foodsand implemented by 9/30/19. All dietary

staff will be educated on this policy. This

poiicywill be formally approved in

Q.uality Council and the Medical

Executive Committee during their August

monthty meetings.

Patient refrigerators: All patient

refrigerators were inspected by the

Director of FaciEities by S/16/19 andwere fou nd to be in good working order.

It was determined that cfietary staff were

aliowlng nursing to stock the

refrigerators and staff have beenstocking the patient refrigerators

excessively. Nursing staff have been

instructed local! the kitchen if they run

out of a particular item prior to the nextdeliver/.



Dietary ManagerDirector of Facilitiesinfection Control Nurse

Dietary ManagerDirector of Facilities

Director of Facilities/

Dietary Manager

8/22/19

9/30/19

9/30/19

9/16/19

The Director of Facilities will observe

housekeeping staff during his monthiy rounds

and provide immediate 1:1 correction if

needed. The Infection Control wiii observe a

minimum of one housekeeper monthly during

their surveillance rounds and report anydeviation from proper process to the Directorof Facflities.

Dietary Manager will ensure all new staff are

trained on this policy upon hire. Random spotchecks of appropriate temperatures will occur

monthly by the Dietan/Manager and the

Infection Control Nurse. All findings will be

reported to the Director of Nursing as well as

the Director of Risk & Quality with anexpected compliance of 100%. This will be

followed for 3 months to ensure sustained

compfiance. After 3 months/monthiymonitoring will continue ard be report&d to

Quality Counc!]. Target date 9/30/19 todevelop and impiement policies as wel! as

train staff.

Movmg forward only dietary staff will stock a

smaller par level of supplies in all of thepatient refrigerators on the units. This will

prevent overstocking and maintain

temperature control inside the refrigerators.

Refrigeratortemperatures are monitored

monthly by infection Control/ daiiy by Directorof Dietary and monthly by. the Director of

Facilities. Any deviation outside the acceptabletemperature range will immediately be

reported to the Director of Facilities.

Handwashing sink in Cafeteria: Anew

handwashing sink will be instailed in the

cafeteria. This wi!i require coordination

with the Department of HealthConstruction Review Service and

installation of new plumbing and a

temporary hand-wash station thatcomplies with WAC 246-215-09225 will

be utilized as an interim solution.

Director of Facilities 1/2G/20 Working w'rth Department of HealthConstruction Review. Mitigation plan until

construction is complete: a handwashingstation in compliance with WAC 246-215-

09225 wili be purchased and placed in thecafeteria.

STATH 01'' WASHINGTON

DEPARTMENT OP HEALTH

October 1,2019

Janet Huff, Director of Risk & QualityCascade Behavioral Health

12844 Military Road STukwiIa,WA 98168

Dear Ms. Huff:

Surveyors from the Washington State Department of Health and the Washington State Patrol FireProtection Bureau conducted a state hospital licensing survey at Cascade Behavioral Health on

July 23 - 26, 2019. Hospital staff members developed a plan of correction to correct deficienciescited during this survey. This plan of correction, including extension requests, was approved on

September 27,2019.

A Progress Report is due on or before October 24, 2019 when all deficiencies have been

corrected and monitoring for correction effectiveness has been completed. The Progress Reportmust address all items listed in the plan of correction, including the WAC reference numbers and

letters, the actual correction completion dates, and the results of the monitoring processesidentified in the Plan of Correction to verify the corrections have been effective. A sample

progress report has been enclosed for reference.

Please mail this progress report to me at the following address:

Robin Munroe, RS

Department of Health, Office of Health Systems OversightPO Box 47874Olympic Washington 98504-7874

Please contact me if you have any questions. I may be reached at 360-236-2914. I am also

available by email at robm.munroc^cloh.wa.Kov.

Sincerely, '^?

Robin Munroe, RS

Survey Team Leader

Documents

IDENTIFICATION NUMBER: Administrative Code (WAC), …L410 Continued From page 4 consistent with this chapter and services provided; (v) Food service consistent with chapter 246-215